What is Hospice

• Hospice care is a type of multidisciplinary care for patients with advanced illness, with the aim of providing comfort rather than reversing underlying disease.
• The Medicare Hospice Benefit provides medical, nursing, counseling, and bereavement services for terminally ill patients and their families.  . Private insurance and Medicaid hospice plans are similar but if your patient has either of these, check on specifics before explaining these to the patient.  
• Hospice is a philosophy of care – not a physical place – and hospice services can be provided in a patient’s home, at a SNF, in a residential facility, or in an acute care hospital. The availability of each of these varies by region, so confirm options in the patient’s home region before discussing them with the patient/family.
• Complete coverage provided for: intermittent nursing care (typically 1-2 visits per week with 24/7 emergency support); social work counseling and planning (living will, DPOA, care coordination); counseling services (including chaplaincy); all medications and supplies related to the terminal illness; durable medical equipment (hospital bed, commode, wheelchair, etc.); home health aide; speech, nutrition, PT/OT; bereavement support to family; short term inpatient care for problems that cannot be managed at home (pain, delirium, caregiver exhaustion); short-term respite care (to provide relief to family caregivers).
• Hospice benefits do NOT cover room and board fees at a facility nor 24/7 nursing care. If either of these are required/preferred, financial considerations must also be discussed as part of care planning.

Who qualifies for hospice?

• Two physicians (i.e. the primary physician and the hospice medical director) must determine patient’s life expectancy to be <6 months if the patient’s illness takes the expected natural course. This does not mean the patient needs to die within 6 months. As doctors typically over-estimate prognosis, consider discussing hospice with patients if you would not be surprised if they died within the next year. Consult palliative care or ask to speak with a hospice medical director if you have questions about a patient’s eligibility.
• In general, hospice replaces life-prolonging therapies in favor of a comfort-based approach. However, patients can still receive antibiotics, diuresis, and even dialysis in the appropriate clinical setting and if they wish to do so. Some patients and families do not want to prolong their lives with these therapies once they have arrived at a point where they are ready for hospice. Consult palliative care or ask to speak with a hospice medical director if you have questions about whether a certain treatment can be provided.

Tips for discussing hospice

• Consider having someone who is very knowledgeable about hospice care (e.g. case manager, social worker, palliative care team) join you for the discussion.
• Discuss prognosis first (at a prior meeting if needed), to make sure that patient and family understand that the prognosis could be as short at 6 months.
• Get a sense of the patient’s goals and what treatments are important to them; only recommend hospice if it seems it would be a good fit for them. Hospice is probably not appropriate for patients who have a preference for invasive and life-prolonging therapies, who prefer to return to the hospital as opposed to receive care at home or a facility, and who are planning to pursue treatments that hospice could not cover such as chemotherapy.
• If hospice seems in line with the patient’s goals, introduce the concept, “It seems like your goals are to focus on comfort and stay at home, but you need more support. One of the best programs for providing that is hospice.”
• Ask patients and families if they have heard of or have any experience with hospice care. Clarify any misconceptions and why you are considering it.
• Clarify that hospice is an interdisciplinary, team based approach to help meet a patient’s and family’s medical, emotional, psychological and social needs, that brings resources to the patient’s home or other facility so that they, ideally, do not have to return to the hospital.
• Emphasize that the decision to pursue hospice is reversible, and that the patient’s current physicians will remain involved in their care. Many patients worry about abandonment.
• Clarify available care settings in the patient/family’s region prior to the meeting and then help them identify the most appropriate setting for hospice care (home, SNF, a hospice facility) based on patient/family preference, caregiver availability, personal care needs, medical complexity, and financial resources. 

Home-based and Outpatient Palliative Care

• All patients with a serious, life-threatening and symptomatic illness (regardless of prognosis) should be discharged from the hospital with a clear plan for palliative care, including symptom management, emotional support, and ongoing discussions about goals of care.
• A patient’s primary care physician or specialty physician may be able to meet these needs, but many other patients benefit from home-based or outpatient specialty palliative care.
• Many home health agencies provide a “bridge” program where hospice nurses and other professionals see patients at home for symptom management and support, even though they are not under the hospice benefit. This can be offered independent from or in conjunction with outpatient palliative care for patients whose goals are not currently in line with hospice but could benefit from additional supports at home.
• Your inpatient palliative care consult team can help identify resources in your area, as can the following website: getpalliativecare.org

References

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. doi: 10.1056/NEJMoa1000678.

www.getpalliativecare.org

Steele LL, et al. The quality of life of hospice patients: patient and provider perceptions. Am J Hosp Palliative Care. 2005; 22:95-110